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Physiotherapy Rehabilitation Protocol

Mrs. Nasrin Hanif Vadwala, 63 years - Right Distal Femur Fracture (Post-ORIF with Lateral Locking Plate)

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X-ray Interpretation

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Current Functional Status Summary

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Key Clinical Considerations Before Starting

• Do not advance weight bearing aggressively until orthopedic surgeon confirms radiographic evidence of callus formation - the fracture is not fully healed.
• Pain is a guide - stop any exercise that causes sharp or worsening bone pain.
• Her knee flexion of 63° suggests significant quadriceps weakness, joint stiffness, and possible adhesions. Target is 90° as the first milestone, then 120°+.
• A 2025 systematic review and meta-analysis (Aebischer et al., ANZ J Surg 2025, PMID 39465540) found that early weight-bearing after distal femur fixation in elderly patients did NOT significantly increase revision or complication rates - supporting a progressive weight-bearing approach under surgical guidance.

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Phase 1 - Protective Phase (Current: Weeks 0-6 post-op baseline)

Modalities

• Cryotherapy (ice pack over knee) - 15-20 minutes, 3-4x/day, especially post-exercise
• TENS or IFT for pain relief over the knee - 20 minutes/session
• Elevation of the limb when at rest

Exercises (Lying / Sitting)

• Lying or sitting
• Pump ankle up and down briskly
• 3 sets x 20 repetitions, 3x/day
• Purpose: Prevent DVT, improve venous return

• Lying flat, roll a towel under the knee
• Tighten the thigh muscle, press knee down into towel, hold 5-10 seconds
• 3 sets x 15 reps, 2x/day
• Purpose: Activate vastus medialis, prevent quad atrophy

• Lying flat, opposite knee bent
• Tighten quad, lift affected leg to 45°, hold 5 seconds, lower slowly
• 3 sets x 10 reps, 2x/day
• Modify: If painful, begin with short-arc quad (SAQ) - see below

• Lying, bolster/rolled towel under knee (30° flexion support)
• Extend knee fully from 30° to 0°, hold 5 seconds, lower
• 3 sets x 10 reps, 2x/day

• Lie on unaffected side
• Lift right leg 30-40°, hold 3 seconds, lower
• 3 sets x 12 reps
• Purpose: Strengthen gluteus medius, prevent Trendelenburg gait

• Lying flat, squeeze buttocks together, hold 5-10 seconds
• 3 sets x 15 reps

• Lying flat, slide heel toward buttocks slowly bending the knee
• Go to pain-free limit (currently ~63°), hold 3 seconds, return
• 3 sets x 10 reps
• Progress: Increase range 5° each week as tolerated

• Sitting at edge of chair/bed
• Use unaffected foot to gently support and assist the right foot in sliding back (flexing knee)
• Hold at end range 15-20 seconds
• 3 sets x 8 reps
• This is the PRIMARY exercise to increase ROM from 63° toward 90°

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Phase 2 - Early Strengthening Phase (Target: Weeks 6-12 from surgery)

Prerequisites to enter this phase:

• Orthopedic surgeon confirms partial healing on X-ray
• Knee flexion reaching 70-80°
• Good quad control with SLR

ROM Exercises

• Sit at edge of high chair or plinth
• Let gravity pull the right leg down gently
• Relax the knee, hold 30-60 seconds
• 3 sets, 2x/day
• Most effective technique for improving flexion beyond 80°

• Lying against a wall, place foot on wall, slide down to increase flexion
• Use opposite foot to gently push further
• Hold 20-30 seconds, 5 reps

• Start at approximately Week 6-8 when ROM reaches 90°
• Begin with seat raised high (less flexion required)
• 10-15 minutes, low resistance
• Progress seat lower as ROM improves

Strengthening Exercises

• Band anchored behind knee
• Straighten knee from 30° to full extension against band resistance
• 3 sets x 15 reps

• Lying face down
• Tighten buttocks and lift right leg 10-15 cm, hold 3 seconds
• 3 sets x 12 reps
• Strengthens gluteus maximus for stair climbing

• Lying flat, both knees bent
• Lift hips off bed, hold 5-10 seconds, lower
• 3 sets x 10 reps
• Progresses to single-leg bridge when able

• Side-lying, both knees bent to 45°
• Open the top knee like a clamshell, keeping feet together
• 3 sets x 15 reps
• Purpose: Gluteus medius for lateral stability while walking

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Phase 3 - Weight-Bearing Progressive Exercise Protocol (Right Leg)

Weight-Bearing Progression Ladder

Weight-Bearing Exercises

• Stand between parallel bars or in front of kitchen counter for safety
• Shift weight side to side slowly, spending 3-5 seconds on right leg
• 3 sets x 10 repetitions
• Progress: Increase time on right leg to 10 seconds

• Stand at counter
• Rise on toes of both feet, hold 3 seconds, lower slowly
• 3 sets x 10 reps
• Purpose: Loading the tibial-femoral chain, calf/soleus strengthening

• Stand facing counter, hold lightly for balance
• Bend both knees to 20-30° (do not go deeper than 45° until healing is confirmed)
• Hold 3-5 seconds, straighten
• 3 sets x 10 reps
• This is the only squat variant appropriate currently given her 63° flexion limit and incomplete healing

• Use a 5-10 cm step initially (increase height as strength improves)
• Step up with the RIGHT foot first (affected leg does the work)
• Bring left foot up, then step down left first
• 3 sets x 8 reps
• Progress to 15-20 cm step height
• Directly trains stair climbing pattern

• Step sideways onto a low step with right foot
• Bring left foot up, return left foot down, then right foot
• 3 sets x 8 reps each direction
• Reinforces side-walking ability

• Use a firm chair (add a cushion to raise seat height initially)
• Lean forward, push through both feet to stand
• Progress: Reduce hand support from both armrests → one armrest → no hands
• 3 sets x 8 reps
• Directly functional for ADL independence

• Hold counter, stand on right leg alone
• Start: 10 seconds, build to 30 seconds
• Progress: Eyes closed, then on foam pad
• Begin only after surgeon approves full weight bearing
• 3 sets x 10-30 seconds

• Practice walking sideways (already partially capable with cane)
• 5-10 meters in each direction
• Helps with hip abductor/adductor coordination
• Progress to sidewalk without cane

• Currently: Ascending and descending with support - continue and refine
• Cue: "Good leg goes up first (lead with left), bad leg comes down first (lead with right when descending)"
• This is the standard step-over-step stair technique for unilateral lower limb conditions
• Progress to step-over-step as ROM and strength improve

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Gait Training Guidance

• Current pattern: Walking with cane in left hand (opposite to affected right leg) - ensure the cane is held in the LEFT hand at all times
• Gait cues: Equal step length, avoid hip hiking or circumduction on the right
• Practice walking on different surfaces: flat floor → carpet → slight incline → outdoor surfaces
• Target: Wean from cane once full weight bearing is achieved and gait is symmetrical

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Pain Management Adjuncts

• Ice 15-20 min after every exercise session
• Transcutaneous Electrical Nerve Stimulation (TENS): 80-100 Hz, 20-30 min for acute pain
• Interferential Therapy (IFT): 4000 Hz carrier, 80-150 Hz AMF sweep, over knee
• Ultrasound therapy over fracture site (1 MHz, 0.5-1 W/cm², pulsed 1:4) - may promote bone healing in delayed union; discuss with orthopedic surgeon
• NSAIDs as prescribed by physician; note long-term NSAID use can impair bone healing - monitor

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Home Exercise Program (Daily)

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Functional Milestones and Targets

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Red Flags - Stop and Refer to Surgeon

• Sudden increase in pain at the fracture site during weight bearing
• Audible click or crack during exercise
• Progressive swelling, redness, warmth (rule out DVT or infection)
• Loss of already gained ROM
• Hardware pain or tenderness over the plate
• Signs of non-union progression on follow-up X-ray

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Evidence Base

• Aebischer et al. (2025), ANZ J Surg - Systematic review/meta-analysis: Early weight-bearing after distal femur fixation in elderly patients does not increase revision or complication rates compared to restricted weight-bearing (PMID: 39465540)
• PMC Case Report (PMC10824706): Phased physiotherapy protocol post distal femur fracture ORIF, progressing from isometric exercises to full weight-bearing with walker to functional activities
• Knee Fracture ORIF Rehabilitation Protocol (Frantz MD): Emphasizes ROM progression, hip abductor strengthening, proprioceptive training after Week 12+

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Joint Mobilization Protocol

Mrs. Nasrin - Right Knee Post Distal Femur ORIF (Incomplete Healing, 63° Flexion, Pain)

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Critical Precautions Before Any Mobilization

• No direct mobilization over the fracture site or the locking plate - hardware is still in situ
• No high-velocity thrust (Grade V) - contraindicated with incomplete bone healing
• No forced end-range mobilization until surgeon confirms adequate callus on X-ray
• Begin with Grade I-II for pain relief; advance to Grade III-IV only when pain is controlled and healing progresses
• Always reassess ROM and pain before and after each mobilization session

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Maitland Grade Selection Guide for This Patient

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1. PATELLOFEMORAL JOINT MOBILIZATIONS (Priority #1)

A. Inferior Patellar Glide (Caudal Glide)

• Therapist stands at the side of the right leg
• Place both thumbs on the superior pole of the patella
• Apply a slow, firm downward (toward the foot) glide
• Hold 10 seconds at end range OR use oscillations 2-3/second
• Grade II: 10 oscillations x 3 sets (current phase - pain relief + early mobility)
• Grade III: 10 oscillations x 3 sets pushed into stiffness barrier (when pain controlled)

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B. Superior Patellar Glide (Cephalad Glide)

• Place thumbs on inferior pole of patella
• Push patella upward (toward the thigh/head)
• Oscillate gently or hold at end range
• Grade II-III

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C. Medial Patellar Glide

• Place index fingers on lateral border of patella
• Push patella medially (toward the midline) with both index fingers/thumbs
• Hold 10-15 seconds at end range
• Grade III-IV for lateral retinacular tightness

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D. Lateral Patellar Glide

• Place thumbs on medial border of patella
• Push laterally
• Grade II initially

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E. Patellar Tilt (Medial Tilt)

• Grip patella between thumb and index finger
• Lift the medial edge while depressing the lateral edge (tilt)
• Hold 10-15 seconds, release
• 5 repetitions

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2. TIBIOFEMORAL JOINT MOBILIZATIONS (Priority #2)

A. Posterior Tibial Glide (Anterior-to-Posterior - for Flexion)

• Therapist at foot end of plinth
• One hand stabilizes the distal femur from above (do NOT press on the plate/fracture area - use the distal shaft proximal to the hardware)
• Other hand grips the proximal tibia from the front with a web-space grip
• Apply a posterior (downward into the table) glide on the proximal tibia
• Direction of force: straight posterior, perpendicular to the tibial shaft
• Grade II: Large amplitude oscillations, short of tissue resistance - 10-20 reps x 3 sets
• Grade III: Large amplitude, into the resistance barrier - 10 reps x 3 sets

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B. Anterior Tibial Glide (Posterior-to-Anterior - for Extension)

• Stabilize distal femur above the hardware
• Apply an anterior (upward/ventral) force on the posterior aspect of the proximal tibia
• Grade II-III
• 3 sets x 10 reps

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C. Tibiofemoral Distraction (Traction)

• Grip the ankle/distal leg
• Apply a gentle longitudinal traction (pull along the tibia axis, away from the femur)
• Grade I-II for pain relief: gentle sustained pull, 30-60 seconds x 3 repetitions
• Never use aggressive distraction with incomplete healing

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D. Medial and Lateral Tibial Glides (Varus/Valgus Accessory Glides)

• Stabilize the distal femur
• Apply a medial or lateral glide on the proximal tibia
• Grade II for pain, Grade III-IV for stiffness
• 3 sets x 10 oscillations in each direction

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3. MULLIGAN MOBILIZATION WITH MOVEMENT (MWM) - When Pain Settles

Mulligan Tibial Glide with Active Knee Flexion

• Therapist applies a lateral tibial glide (medial-to-lateral direction) on the proximal tibia with both hands
• WHILE the therapist sustains the glide, the patient actively flexes the knee as far as possible - pain free
• If flexion increases without pain - this is the correct direction
• If not, try medial, anterior, or posterior glide direction until pain-free movement is found
• Hold at end range 10 seconds, return
• 3 sets x 10 reps

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4. SOFT TISSUE MOBILIZATION (Adjunct)

A. Quadriceps Soft Tissue Release / Massage

• Longitudinal effleurage and petrissage to the quadriceps muscle belly (distal 1/3 - avoid directly over plate)
• Reduces quad tightness which mechanically restricts knee flexion
• 5-10 minutes per session

B. Popliteal Fossa / Posterior Capsule Stretching

• Supine, therapist gently applies sustained pressure into popliteal fossa while extending the knee
• Addresses posterior capsular tightness that limits full extension
• 3 x 30-second sustained holds

C. Iliotibial Band (ITB) Release

• Side-lying, therapist applies lateral thigh friction massage
• Reduces lateral knee tightness that contributes to patellar mal-tracking
• 5 minutes

D. Scar Tissue / Adhesion Release Around Incision

• Once wound is fully healed (>6 weeks post-op, scar mature)
• Circular friction massage perpendicular to and parallel to the incision scar
• Mobilizes the scar to prevent adhesion to underlying fascia/hardware
• 3-5 minutes per session

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5. CONTINUOUS PASSIVE MOTION (CPM) - If Available

• Passive mechanical flexion-extension cycling
• Range: Start at 0-60° (her current limit), advance 5° every 1-2 days as tolerated
• Duration: 1-2 hours/day
• Excellent for maintaining gains between manual mobilization sessions
• Particularly useful when therapist is not available

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Session Structure for Each Physiotherapy Visit

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Expected ROM Gains with Consistent Mobilization

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Stop Mobilization If:

• Pain significantly worsens during or after mobilization (especially bone pain at fracture site)
• New swelling develops acutely after session
• Fever or signs of infection
• Radiographic evidence of hardware loosening at next follow-up